Client Health Assessment Flashcards

A practical nurse is preparing to perform a physical assessment on an older adult client who has just been admitted to a long-term care facility. Which of the following actions should the nurse take first?

Answer: Explain the assessment process and ask for consent.

Before beginning any assessment, the practical nurse must first explain the procedure to the client and obtain their informed consent. This action respects the client's autonomy and establishes a therapeutic relationship based on trust. While gathering history, taking vital signs, and inspection are all crucial parts of the assessment, they should only occur after consent is given.

When assessing the abdomen of a client complaining of abdominal pain, what is the correct sequence of assessment techniques the practical nurse should use?

Answer: Inspection, Auscultation, Palpation, Percussion

The correct order for an abdominal assessment is Inspection, Auscultation, Palpation, and then Percussion. Auscultation is performed before palpation and percussion because physically manipulating the abdomen can alter bowel sounds, leading to an inaccurate assessment.

A practical nurse is conducting a health history interview with a new client. Which of the following is an example of an open-ended question?

Answer: "Describe the pain you are feeling."

An open-ended question encourages the client to provide a detailed narrative response rather than a simple 'yes' or 'no'. "Describe the pain you are feeling" prompts the client to elaborate on their symptoms, yielding more comprehensive subjective data. The other options are closed-ended questions that elicit specific, limited responses.

During a skin assessment of a client with limited mobility, the practical nurse notes a reddened, non-blanchable area over the sacrum. The skin is intact. How should the nurse document this finding?

Answer: Stage 1 pressure injury

A Stage 1 pressure injury is characterized by intact skin with a localized area of non-blanchable erythema. This finding indicates that the client is at significant risk for further skin breakdown, and preventative interventions are required immediately.

Which of the following is considered subjective data in a client's health assessment?

Answer: The client states, "I feel nauseous."

Subjective data is information reported by the client from their own perspective, such as feelings, perceptions, and concerns. The client's statement of feeling nauseous is subjective. Respiratory rate, blood pressure, and the presence of a rash are all objective data that can be observed and measured by the nurse.

A practical nurse is assessing the level of consciousness of a client who has sustained a head injury. Which assessment tool is most appropriate for the nurse to use?

Answer: Glasgow Coma Scale (GCS)

The Glasgow Coma Scale (GCS) is a standardized tool used to objectively assess a client's level of consciousness by evaluating eye-opening, verbal, and motor responses. The Braden Scale assesses risk for pressure ulcers, the Morse Fall Scale assesses fall risk, and PQRST is a mnemonic for pain assessment.